Are the Norwegian health research investments in line with the disease burden?

In the US in 1997 the National Institute of Health’s working group on priority setting recommended using public health needs as a criterion for research [1]. Similar recommendations have later been made in other countries [2], which has motivated research to assess the correlation between research funding and measures of disease burden. Some of these studies, which have been conducted in the US, the UK, and Australia, reveal high correlations between research funding and measures of disease burden [1, 3–7]. However, other studies dispute this [2, 6, 8, 9], and cancer, in particular, appears to attract more funds relative to disease burden compared with other diseases [2, 5, 7, 9]. Some of the literature in this field has examined different cancers with the general finding that breast cancer attracts more funding relative to disease burden than other types of cancer [1, 3, 6, 8].

While the association between research funding and burden of disease has been investigated in several countries, little attention has been paid to national research investments and global disease burden. Such considerations are important given recent calls for new strategies for incorporating a global perspective into investments in health research [10–12]. Health threats, as a result of globalization, are becoming increasingly transnational and social determinants of health at the national level are influenced by global markets, migrations, and communication. Efficient management of global health resources are thus needed. Furthermore, it can be argued that Norway, as a rich country, has a special responsibility to conduct research that reflects the health needs of developing countries [13].

It has been suggested that health need is a key criterion for deciding the allocation of resources for both treatment and research [14, 15]. However, health need alone is not a sufficient criterion to determine research priority, i.e., twice the health need does not justify twice the investment in research. Such a decision must also depend on the opportunity for progress in the area. Without this consideration, less overall scientific progress in the field of health research would be accomplished, which would lead to less of a reduction in the burden of disease than what could have been achieved otherwise. In addition, there are a range of other criteria, such as feasibility of the intervention, equity, and cost-effectiveness, which must be included in a comprehensive analysis to ensure that important considerations are not overlooked. Hence, this is not a prioritization analysis, but rather a contribution to the debate on global research funding.

The aim of the following analysis was to assess the correlation between Norwegian research investments and both the Norwegian and global burden of disease. This was possible as both the Research Council of Norway and the Regional Health Authorities have adopted the International Health Research Classification System (HRCS) to classify part of their efforts in health research [16]. As a measure of Norwegian and global morbidity/mortality, we used data from the International Global Burden of Disease (GBD) 2010 project [17, 18].

The correlation coefficients demonstrate a high correlation between the total research investments included in the analysis and associated disease burden, in terms of YLLs and DALYs, in Norway (Table 1). The correlations between the Norwegian disease burden and total research investment were 0.73 for YLLs and 0.62 for DALYs. The correlations between total research investments and the global disease burden were 0.11 for YLLs and 0.12 for DALYs and were thus considerably weaker than in the Norwegian case. The correlation between Norwegian disease burden and investments was more pronounced for the RHAs than for the RCN. In contrast, at the global level, RCN investments correlated more with disease burden than the RHAs’ investments. The correlations between the RHAs’ investments and global YLLs and DALYs were 0.05 and 0.04, respectively, i.e., almost non-existent.

The share of total research investments increased with the relative ratios. This means that disorders with a particularly high disease burden in Norway, relative to the global burden, attracted relatively more investments. Conversely, it could mean that less was invested if the disease burden was low in Norway relative to the rest of the world. The positive correlation was higher for RHAs (0.53) than for the RCN (0.41). This suggests that RHAs are more focused on the Norwegian disease burden, while the RCN has a more global profile.

Figure 1A–D displays the results from Table 1 with scatter plots supplemented with linear regression lines of the correlations. Figure 1A illustrates how the disease category cancer, which accounted for a large proportion of the YLLs, had the highest research investments. We also see that cardiovascular diseases received less funding than both cancer and mental health. Figure 1B demonstrates the consequence of taking both YLLs and morbidity into account through DALYs. Compared with YLLs, both cardiovascular disease and cancer are relatively less important, while the magnitude of health loss from both musculoskeletal diseases and mental health increases significantly.Figure 1C, D illustrates the results based on the global YLLs and DALYs. Although the global trends were similar to those of Norway, there are important differences of which the most important is the increased burden from infectious diseases. As Norway funds relatively little research on this disease category, the correlations are weaker than that seen when comparing with the Norwegian disease burden.Figure 2 illustrates the relative Norwegian DALYs to the global DALYs by disease category. This is mapped against the total research investment included in the analysis. As shown in the figure, the burden of musculoskeletal disorders has been especially high in Norway, but the research investments have been relatively low. The burden of diseases related to reproductive health and childbirth as well as infectious diseases was very small in Norway. With the exception of musculoskeletal disorders, the RCN and RHAs invested more in diseases in which the disease burden was high in Norway compared with the rest of the world.

We found that a significant part of research investment in the health sector in Norway was highly correlated with the disease burden in Norway, although with some exceptions. This is important as it demonstrates that investments in research largely follow the health needs of the Norwegian population. The association between investments and the Norwegian disease burden was more pronounced for the RHAs compared with the RCN. In addition, we compared the Norwegian research investments with the global disease burden and found a positive correlation. However, the association was less pronounced, compared to the correlation between research investments and the Norwegian disease burden. Finally, we illustrated, using rates, that when the relative burden in Norway was high, compared with the global burden, this disease attracted more funds.

Different measures of disease burden can be used to focus attention on different aspects of the disease [26, 27]. YLLs measures have been found to better predict research funding than mortality [1, 27]. However, composite measures of disease burden that include both morbidity and mortality, like DALYs, have been found to correlate more with funding that YLLs [1, 3]. We explored the use of two measures of disease burden – YLLs and DALYs – and found that the choice of either measure highly influenced the ranking of disease categories. This disparity was primarily manifested within non-fatal disorders. For example, musculoskeletal and mental health disorders had a low impact on disease burden when YLLs was used as the sole criterion. However, when a composite measure of both mortality and morbidity through DALYs was applied, the burden from such disorders increased vastly. Such variations demonstrate how policy makers could be misled. By using a single measure of burden, advocates interested in promoting research on specific diseases could select measures that support their cause [1].

Norway, as a rich country, may have a special responsibility to conduct research that reflects international priorities and contribute knowledge that can support the formulation of international health initiatives. Further, the disease burden is a central criterion for setting priorities in health research [14, 15, 28]. Our analysis shows that musculoskeletal, neurological and mental health illnesses were less important for the global burden compared with the Norwegian burden. Conversely, infectious diseases, reproductive health, and childbirth complications were pivotal globally, particularly in developing countries. One might argue that these diseases deserve particular attention as developing countries with low GDP per capita have few resources available for health research [15].

The findings suggest that the RCN investments are more globally oriented than those of the RHAs. For example, a larger share of the RCN’s investments was invested in research on reproductive health and childbirth complications, while the RHAs invested more in musculoskeletal disorders. This is not surprising given that the RHAs are responsible for covering all clinical areas and invest in clinical research to a greater extent than the RCN. In addition, hospitals indeed pay particular attention to local needs, while the RCN has a major program initiative in global health research.

In the portfolios we have analyzed, only a minor part were the direct result of overall prioritization of certain disease areas over others. It is therefore interesting that, in a collection of portfolios which are distributed mainly based on competition and without prioritized disease areas, we see a positive correlation between financial input and disease burden. This is a sign that the Norwegian research system seems to sufficiently cover the range of clinical activity and that there is room for high quality research on most disease areas of importance.

We emphasize that the need criterion is not sufficient for an efficient allocation of resources and cannot be used exclusively for priority purposes as important parts are lacking. The goal of activities to set priorities for health research is to define an investment portfolio of health research and development that will have the greatest possible impact on the health of the majority of the population [14]. To achieve this, other aspects must be taken into the analysis such as the efficiency criterion (the higher the priority, the higher the potential health benefits) and the cost-effectiveness criterion (the higher the priority, the greater the health benefit per invested funds). To conduct a full prioritization analysis one would need additional evidence on the costs of the disorders and, importantly, the potential for scientific progress [1]. Further, there are other important goals and drivers in Norwegian research policy such as the need to stimulate a more research-intensive private sector, foster high quality research and scientific excellence, and utilize national advantages. Different criteria are applied depending on the context and research area.

The aim of the current study was not to suggest how much Norway should spend on particular disease groups, but rather to inform decisions on the distribution of research effort. The research investments included in the analysis were highly correlated with the Norwegian disease burden. However, the correlation with the global disease burden was much lower. Generally, diseases that were relatively important in Norway compared with the rest of the world attracted more investments.